VBS Teen Volunteer Form

* Indicates required field

Youth Name *

First

Last

Birthdate *

grade in fall 22 *

Youth T-shirt size (adult sizes) *

S M L XL

Parent Email *

Parent Phone Number *

This Medical Release Form will cover all activities of St. John Parish Vacation Bible School from June 20 – June 24, 2022.
ARCHDIOCESE OF CINCINNATI
RELEASE AND INDEMNIFICATION AND MEDICAL POWER OF ATTORNEY

I, the lawful parent or guardian of ___________________________(the “child”), give permission for my child to participate in the activity described on the reverse side, and release from all liability and indemnify the Archbishop of Cincinnati (“the Archbishop”), both individually and as trustee for the Archdiocese of Cincinnati and all parishes within the Archdiocese, and their officers, agents, representatives, volunteers, and employees from any and all liability, claims, judgments, cost or expenses, including attorney fees, arising out of any injury or illness incurred by my child while participating in or traveling to or from the activity.
I agree to instruct my child to cooperate with the Archbishop or his agents in charge of the activity.

3a. I appoint the Archbishop or his agents who are acting as leaders of the activity as my attorney in fact to act for me in my name and my behalf, in any way that I would act if I were personally present, with respect to the following matters if any injury, illness or medical emergency occurs during the activity or related travel:

To give any and all consents and authorizations to any physicians, dentist, hospital or other persons or institutions pertaining to any emergency medications, medical or dental treatments, diagnostic or surgical procedures or any other emergency actions as our attorney shall deem necessary or appropriate for the best interest of the child.
I understand that the agents of the Archbishop will make a reasonable attempt to contact me as soon as possible in the event of a medical emergency involving my child.

3b. The powers and authority granted herein may be revoked by me by written notice delivered to the Archbishop or his agents who are then acting or who have previously acted hereunder. Without such written notice, this power of attorney shall not be affected by my disability, incapacity or adjudicated incompetence. This power of attorney shall lapse automatically at the end of above said time period.
4. I agree that the Archbishop or his agents may use my child’s portrait or photograph for promotional purposes and office functions, and hereby release the Archbishop and his agents from any liability resulting from such use.

I have carefully read this statement, and my signature acknowledges that I fully understand its content and meaning.

signature of parent/guardian *

date *

preferred Phone Number *

home Address *

Line 1

Line 2

City

State

Zip Code

Country

other emergency contact *

relationship to youth *

Phone Number *

youth's medications *

Allergies/Chronic conditions (e.g. epilepsy, ADHD, diabetes) *

medical insurance company *

policy number *

member's name *

Phone Number *

child's doctor *

Phone Number *

Activity Information

Church Agency:                      St. John the Evangelist Parish
Program:                                 Vacation Bible School
Registration Fee:                     Free for Teen Volunteers (grades 7 & up, Fall, 2022)
Meeting Dates & Time:           June 20 – June 24, 2022, 8:30am- 12:00pm
Activity Location:                    St. John the Evangelist, Parish Education Center
                                                9080 Cincinnati-Dayton Rd. West Chester, OH 45069
Activities Involved:                  Music, Skits, Games, Snacks, Large & Small Group Gatherings
Event Leader:                          Mary Montour, Pastoral Associate, Children’s Faith Formation
Phone Contact:                       513-755-4973, or 513-777-6433, x.118, or Cell: 513-708-2654

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